A nurse on a postpartum unit is caring for a client.

Exhibits

For each finding, click to specify if the finding is consistent with uterine atony or infection. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Prolonged rupture of membranes

Polyhydramnios

Prenatal anemia

High parity

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Prolonged rupture of membranes: Rupture of membranes lasting longer than 18 hours increases the risk of ascending bacterial infection, leading to conditions such as endometritis. This is a known risk factor for postpartum infection, especially following cesarean delivery.
Polyhydramnios: An excessive amount of amniotic fluid overdistends the uterus, which can impair its ability to contract effectively postpartum, making uterine atony more likely. Atony can lead to increased bleeding or retained lochia.
Prenatal anemia: While not directly causing infection, anemia impairs immune function, increasing a person's susceptibility to postpartum infections. It can also worsen recovery from infections or surgical wounds.
High parity: Multiple prior pregnancies stretch the uterus over time, reducing myometrial tone, which predisposes to uterine atony. This makes it harder for the uterus to contract adequately after delivery, increasing the risk for hemorrhage or subinvolution.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Place an ice pack over the cast. While this can help reduce swelling and pain, it is a comfort measure, not the priority. Safety assessments must be completed first before implementing non-urgent interventions.
B. Position the casted extremity on a pillow. Elevation is important to reduce swelling, but it follows after ensuring that circulation to the extremity is intact and that there are no signs of vascular compromise.
C. Teach the client to keep the cast clean and dry. Education is essential for long-term cast care, but it is not the first action after cast application. Immediate post-procedural monitoring takes precedence.
D. Palpate the pulse distal to the cast. The nurse should first assess for adequate circulation by checking distal pulses. This helps identify early signs of complications like compartment syndrome or impaired blood flow, making it the highest priority.

A. "Remain on bed rest for 24 hours following the procedure." B. "Participate in range-of-motion exercises." C. "Place a pillow under your knees while in bed." D. "Use an incentive spirometer every 4 hours."

Correct Answer is B

Explanation

A. "Remain on bed rest for 24 hours following the procedure." Prolonged bed rest increases the risk of venous thromboembolism (VTE) and pulmonary complications. Early ambulation or movement is encouraged to promote circulation and prevent complications.
B. "Participate in range-of-motion exercises." Range-of-motion (ROM) exercises help stimulate venous return, improve circulation, and prevent blood stasis, which lowers the risk of postoperative blood clots and muscle stiffness.
C. "Place a pillow under your knees while in bed." Placing a pillow under the knees can impair circulation and increase the risk of venous stasis and thrombus formation. It is not recommended for circulation promotion.
D. "Use an incentive spirometer every 4 hours." While this instruction helps prevent respiratory complications, it is not a direct intervention for improving circulatory function. It's primarily used to promote lung expansion postoperatively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor?

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A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?

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A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete?

A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy. Exhibits Complete the following sentence by using the lists of options. The child is at risk for developing dropdownas evidenced by theirdropdown. anddropdown.

A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg. Which of the following actions should the nurse take to protect the client's confidentiality?